SKINTED: A rare cutaneous complication following total knee replacement surgery

A 63-year-old female presented with skin lesions involving the inferolateral aspect of the bilateral knee for 1 month, associated with mild itching. She had undergone total knee replacement (TKR) surgery for both the knees 9 months back. There was no history of atopy, any topical application, or trauma at the site of lesions. Examination revealed erythematous, eczematous plaques inferolateral to the incision site of both knees [Figures 1a and b]. Owing to the history of TKR and the classical site of involvement, a diagnosis of surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis (SKINTED) was made. She was treated with emollients and mometasone cream. SKINTED is a site and procedure-specific dermatosis involving the skin lateral to the surgical incision in TKR surgery.^[1]

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Figure 1:

Eczematous plaques involving inferolateral aspect of total knee replacement incision site right knee. (a) Left knee, (b) Right knee.

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Verma and Mody et al. proposed the term SKINTED after observing that around 55 patients who underwent TKR surgery had xerotic, erythematous plaques adjacent to the TKR site.^[1] Lesions in SKINTED were attributed to cutaneous nerve transaction, causing an increase in transepidermal water loss and deficient substance P and acetylcholine, manifesting as eczematous skin lesions.^[1]

Differential diagnoses include allergic contact dermatitis, surgical site infection, and allergy to metal implants. Allergic contact dermatitis occurs as pruritic, eczematous lesions usually secondary to tissue adhesives, bandages, wound closure materials, or topical medications.^[2] Surgical site infection presents with signs of acute inflammation such as swelling, erythema, tenderness, purulent discharge, and fever. Metal hypersensitivity can present as periprosthetic synovitis and swelling.^[3] Eczematous dermatitis can also occur in metal hypersensitivity, which can present as localized lesions involving either side of the scar and sometimes involving remote areas secondary to systemic contact dermatitis.^[3] On the contrary, SKINTED tends to involve the lateral aspect of the surgical scar with minimal symptoms. SKINTED responds favorably to emollients and topical steroids. The present case is reported to highlight this often missed cutaneous complication following TKR surgery.